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The JPMorgan Chase Institute Healthcare Out-of-pocket Spending Panel (JPMCI HOSP) included 2.3 anonymized Chase customers from 18 to 64 years old between 2013 and 2016. The study examined trends in out-of-pocket healthcare spending in 23 of the 50 United States and their effects on household financial standings.

“[The panel] provides a first-ever look into out-of-pocket healthcare spending for households on a month-to-month basis, at the state, metro and county level, and as recent as 2016,” wrote the authors. “In this report, we describe the creation of, and initial insights gleaned from, this new data asset.”

Out-of-pocket payments included those made via a credit card, debit card or electronic bill pay. They excluded those made with cash, check, non-Chase cards, premium payments, and health insurance reimbursements.

1. Average spending increased, but remained static as share of take-home pay.

Between 2013 and 2016, out-of-pocket spending on healthcare jumped up from $629 per family to $714—and increase of 14 percent. But healthcare remained spending remained relatively constant as a share of take-home income (1.7 percent in 2013; 1.6 percent in 2016) and total spending (1.1 percent; 1.2 percent).

“Insurance coverage growth had the dual effects of lowering a family’s out-of-pocket healthcare obligations for a given unit of care, but also increasing utilization of healthcare services among families who newly gained health insurance coverage,” researchers wrote.

As one would guess, older individuals and those who earned more money spent more on healthcare. Those between 55 and 64 averaged $827 in out-of-pocket expenses in 2016, compared to $265 for 18- to 25-year-olds and $535 for 26- to 34-year-olds. Those with take-home income over $92,000 spent an average of $1,322 compared to $356 for those with income below $24,000.

The most telling statistic, though, is spending as a fraction of income. Those earning over $92,000 spent just 1 percent, compared to 2.8 percent for those in the lowest quintile (under $24,000).

“Account holders with higher incomes may have consumed a higher quantity of healthcare or higher priced healthcare or been obligated to pay a higher share of healthcare expenses incurred,” the team stated. “Account holders with lower income bore a higher burden of healthcare spending even though they spent fewer dollars on healthcare.”

3. More than half of all spending went to doctors, dentists and hospitals.

Out-of-pocket payments for drugs accounted for only 8 percent of all spending, while doctors (22 percent), dentists (21 percent) and hospitals (12 percent) were the largest recipients.

Doctors were the most common, but dentists received the largest average payments ($465).

4. Ten percent of the population accounted for nearly half (49 percent) of total spending.

Spending was heavily concentrated among a few families. The top 10 percent accounted for 49 percent of overall spending (averaging $3,482 per family). Conversely, half of all families spent less than $213 per year, with 20 percent of families racking up no out-of-pocket spending.

“High-burden families tended to remain high-burden families over time. Among families who were in the top 10 percent of healthcare spending burden in 2015, half remained in the top 10 percent of burdened families in the next year,” wrote the authors. “In comparison, among families in the bottom 10 percent of healthcare burden in 2015, just 30 percent remained in the bottom 10 percent of healthcare burden in 2016.”

5. Spending habits mirrored spikes and valleys in take-home income.

Spending tracked closely with take-home income—clearly visible in upticks in spending in March and April, when 80 percent of tax filers receive a refund. Similar to the No. 2 bullet point, older, high-income and female account holders were more likely to have out-of-pocket spending above $1,000.

Only 4 percent of those under 25 spent were considered to have high spending, compared to 11 percent for the three age groups older than 35 years old. Just 5 percent of those earning less than $24,000 in take-home pay spent more than $1,000 in 2016, compared to 15 percent of those making more than $92,000.

“Out-of-pocket healthcare spending was higher not just among high-income families compared to low-income families but also, for a given family, in the months and the years in which they had higher take-home income and liquid assets,” according to the study.

6. The burden of healthcare spending varied significantly from state to state.

Of the 23 states covered in the Chase report, Colorado had the highest average out-of-pocket spending per family, at $916, followed next by Utah ($906). California had the lowest average spending ($596) with Michigan the No. 2 at $601.

But looking at the spending burden as a percent of total income, Oklahoma and Louisianna had the highest rates, at 1.7 percent, while New Jersey and New York averaged just 1 percent.

In conclusion, the report made three recommendations for healthcare reforms to help those especially burdened by out-of-pocket spending:

First, out-of-pocket healthcare expenses represent a stable share of household income in aggregate, but are a source of financial strain for certain families. Healthcare reform should take into consideration the impact on households who are more financially burdened by healthcare expenses—specifically older, low-income, and female account holders. Second, healthcare spending may be large, unexpected, and concentrated in the months and years when families have a higher ability to pay. As such, consumers would benefit from more transparent pricing and payment options to better manage healthcare expenses. Third, cost containment measures, including value-based care, could have meaningful impacts on costs borne by families, not just by insurers and healthcare providers. Finally, wide variation in levels and burden of healthcare spending across geographies underscores the importance of healthcare as a state and local policy issue.